Visit nonadherence, that is, "no shows," in psychiatry costs the US healthcare $100 billion every year. Nonadherent visits undermine healthcare quality improvement efforts and erode patients' health. Previous research has focused on patient demographics or on redundant scheduling, rather than on the actual structure of visit nonadherence. Drawing on a comprehensive literature review and a series of 3 studies, we identify 22 determinants that contribute to visit nonadherence. Significantly, 8 of these determinants seem to account for most of the variance in modeling visit nonadherence. This work lays the foundation to develop prognostic tools for reducing nonadherent visits in ambulatory care.
Two patients with dense erythematous non-blanching rash of rapid spread are discussed here with implications for management. In each case, the rash appeared after co-administration of Aripiprazole with Lamotrigine and the reason for appearance of the rash remains unclear. In Case 1, the rash resolved despite the continuation of Lamotrigine and stopping Aripiprazole. In Case 2, the rash resolved despite continuing Aripiprazole and stopping Lamotrigine.
| C A S E 1T is a 31-year-old male with a known history of Oppositional Defiant Disorder, Attention Deficit Hyperactivity Disorder, and a medical history of absence seizures presenting on involuntary basis in the setting of mania. T was admitted after threatening to kill step-father with a knife. On admission, home medications were provided including Lamotrigine 150 mg twice daily (BID), Adderall 10 mg qAM was held, and treatment for presenting symptoms was initiated with addition of aripiprazole 5 mg Daily for the diagnosis of Bipolar I Disorder. Fourteen days after initiating aripiprazole, on day 2 of 10mg dose, a rash erupted and is shown in Figure 1. The rash was noticed upon awakening due to pruritus and was characterized as a dense erythematous macular appearing rash that started at abdomen and pelvis with areas of coalescence and rapidly spread to extremities as well as oral mucosa. T had no known previous allergies or recent viral illness. Of note, he had a previous diagnosis of ulcerative colitis; however, he did not have cutaneous complication and did not have current gastrointestinal symptoms.
| C A S E 2G is a 24-year-old female with a known history of Bipolar I Disorder admitted involuntarily for disorganized behavior and inability to sleep in the setting of psychotic mania. On admission, her home medication was started, 400 mg of long acting injectable (Abilify Maintena®) with an oral formulation of 10 mg/d for 2 weeks. Four days later, lamotrigine was started with standard titration schedule at 12.5 mg BID which she tolerated well. Fifteen days after starting aripiprazole and 11 days after starting lamotrigine, a rash erupted on her trunk with rapid spread to extremities, shown in Figure 1. The rash was characterized as a dense erythematous macular rash with coalescence in the pelvic region with involvement of the genital mucosal surfaces.
| DERMATOLOGY CONSULTATION FOR TRE ATMENT OF R A S HDermatology was consulted for each case ruling out Drug-induced Eosinophilic Systemic Syndrome (DRESS), Toxic Pustuloderma, Erythema Multiforme as these entities can commonly present in similar fashion. Dermatology findings were consistent with early stages of Stevens Johnson Syndrome (SJS) as the rash was non-blanching with areas of coalescence involving mucosal surfaces though blistering or pustules had not formed. Important testing included critibal blood count for ruling out eosinophilia, assessing amount of skin involvement to rule out toxic epidermal necrolysis. Skin biopsy was considered; however, it was not pursued by dermatology as the rash ceased spread a...
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